Healthcare Provider Details

I. General information

NPI: 1235460817
Provider Name (Legal Business Name): MRS. IRINA V. FEWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 01/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7918 N 9TH PL
TACOMA WA
98406-1091
US

IV. Provider business mailing address

7918 N 9TH PL
TACOMA WA
98406-1091
US

V. Phone/Fax

Practice location:
  • Phone: 253-460-7289
  • Fax:
Mailing address:
  • Phone: 253-460-7289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberMC12476
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: